S T U D Y P R O T O C O L
Open Access
Expectations, experiences and attitudes of
patients and primary care health professionals
regarding online psychotherapeutic interventions
for depression: protocol for a qualitative study
Jesús Montero-Marín
1,2, José Miguel Carrasco
3, Miquel Roca
4, Antoni Serrano-Blanco
5, Margalida Gili
4,
Fermin Mayoral
6, Juan V Luciano
5, Yolanda Lopez-del-Hoyo
7, Barbara Olivan
7, Francisco Collazo
8, Ricardo Araya
9,
Rosa Baños
10,12, Cristina Botella
11,12and Javier García-Campayo
1,13*Abstract
Background:In the year 2020, depression will cause the second highest amount of disability worldwide. One quarter of the population will suffer from depression symptoms at some point in their lives. Mental health services in Western countries are overburdened. Therefore, cost-effective interventions that do not involve mental health services, such as online psychotherapy programs, have been proposed. These programs demonstrate satisfactory outcomes, but the completion rate for patients is low. Health professionals’attitudes towards this type of
psychotherapy are more negative than the attitudes of depressed patients themselves. The aim of this study is to describe the profile of depressed patients who would benefit most from online psychotherapy and to identify expectations, experiences, and attitudes about online psychotherapy among both patients and health professionals that can facilitate or hinder its effects.
Methods:A parallel qualitative design will be used in a randomised controlled trial on the efficiency of online psychotherapeutic treatment for depression. Through interviews and focus groups, the experiences of treated patients, their reasons for abandoning the program, the expectations of untreated patients, and the attitudes of health professionals will be examined. Questions will be asked about training in new technologies, opinions of online psychotherapy, adjustment to therapy within the daily routine, the virtual and anonymous relationship with the therapist, the process of online communication, information necessary to make progress in therapy, process of working with the program, motivations and attitudes about treatment, expected consequences, normalisation of this type of therapy in primary care, changes in the physician-patient relationship, and resources and risks. A thematic content analysis from the grounded theory for interviews and an analysis of the discursive positions of participants based on the sociological model for focus groups will be performed.
Discussion:Knowledge of the expectations, experiences, and attitudes of both patients and medical personnel regarding online interventions for depression can facilitate the implementation of this new psychotherapeutic tool. This qualitative investigation will provide thorough knowledge of the perceptions, beliefs, and values of patients and clinicians, which will be very useful for understanding how to implement this intervention method for depression.
Keywords:Depression, Online psychotherapy, Internet-based treatment, Protocol, Qualitative study
* Correspondence:[email protected]
1Department of Psychiatry, University of Zaragoza, Zaragoza, Spain 13
Psychiatry Service, Miguel Servet Hospital, Avda Gomez Laguna 52, Zaragoza 4D 50.009, Spain
Full list of author information is available at the end of the article
Background
Reports from the World Health Organization say that de-pression will cause the second highest level of disability worldwide by the year 2020 [1]. It is also known that 25% of the population will experience depression symptoms at some point in their lives [2]. Studies confirm that 25-35% of patients visiting primary care suffer from a psychiatric disorder and that more that 80% of these cases are minor psychiatric disorders, mainly depression and anxiety [3]. It is known that family physicians only refer 5-10% of the psy-chiatric pathologies that they detect to mental health services [4]. Despite this low referral rate, mental health services in Western countries are overburdened. Given the high prevalence of minor psychiatric disorders, health officials worldwide assume that it is not possible to count on the availability of mental health professionals or eco-nomic resources to meet this need, and the situation will become even more unfavourable in the near future [5]. For this reason, cost-effective alternatives are being proposed for the treatment of minor psychiatric disorders in general, and depression in particular, that do not involve (or only minimally involve) mental health services. The therapeutic solutions that are most frequently investigated are brief psychotherapies that can be administrated from a personal computer, such as conflict resolution therapy [6], biblio-therapy [7], self-help programs [8] and computer-assisted psychotherapy programs [9].
The term “computer-assisted psychotherapy” is used to refer to any psychotherapy program (all programs currently available use cognitive-behavioural therapy) that uses the patient’s responses to perform some type of decision-making about treatment [10]. This term ex-cludes videoconferences and self-help programs that in-volve exclusively bibliotherapy, chats, or support groups, among other approaches. Computer programs decrease the work of psychotherapists by more than 80% but do not eliminate it completely. In fact, it has been shown that treatment programs with no human intervention are associated with a higher frequency of dropouts, so their effectiveness is lower. Patients tend to access ther-apy from a home computer and usually complete short sessions, approximately 20 minutes long, at least once a week for 3–6 months [10]. Research has assessed the ef-fectiveness of computer-assisted psychotherapy for treating psychiatric disorders as varied as anxiety, de-pressive disorders, alcohol abuse, and psychosomatic illnesses [11-13]. Recent research on the cost-effectiveness of computer-assisted psychotherapy has yielded very satisfactory results [14,15].
In the specific case of depression, studies show that computer-assisted psychotherapy is effective for the treatment of light and moderate depression [9]. This re-sult has led the National Institute for Health and Clinical Excellence of the British National Health Service to
support the widespread use of a computer-assisted psy-chotherapy program (“Beating the Blues”) in the treat-ment of depression [10]. Other studies show that computer-assisted psychotherapy is very effective, indi-cating that the program could be viable not only at the primary care level but also in the mental health ser-vices context. Computer-assisted psychotherapy could be recommended as a first treatment step for self-help in treating depression and anxiety before visiting a psychiatrist or psychologist [16]. Recent studies have evaluated computer-assisted psychotherapy programs, such as“Blues Begone”, in which there is no psychother-apist present and the program can be administered com-pletely by the patient [17]. The effectiveness of this type of program is also very high, and its use has been evaluated through naturalistic studies and randomised trials [17,18]. The effect size is 0.5 (Cohen’s d) when analysed by intention to treat and 1 (Cohen’s d) when only the patients who complete the program are analysed. In addition, effectiveness is maintained 6 months after finishing the therapy program [18]. Other computer-assisted intervention models are being tested in which treatment is delivered by a therapist in real time via the Internet, and the results of these tests are positive in terms of effectiveness and acceptability [19].
This type of therapy produces a very positive expect-ation in patients and a high degree of satisfaction [20,21]. However, there are some limitations to its systematic use. The completion rate for patients in clinical trials is 56%. In most cases, patients withdraw for personal reasons, not because of problems with the technology or the social environment. Interestingly, the attitudes of professionals towards this type of psychotherapy are more nega-tive than the attitudes of patients themselves [20,21]. There are few previous studies on the acceptability of computer-based psychotherapy, particularly in the pri-mary care setting [20].
Objectives
The first objective of this research is to describe the pro-file of depressed patients who would benefit the most from online-assisted psychotherapy. The second object-ive is to identify expectations, experiences, and attitudes among both patients and health professionals that may serve as barriers to or facilitators of online-assisted psy-chotherapy by considering the types of information that they require throughout the therapeutic process for ad-equate intervention development.
Methods
Design
Through in-depth interviews [22], first, an attempt will be made to understand the experiences of depressed patients with online psychotherapy interventions, the reasons why people decided to end treatment, and the expectations of those who are not treated (considered separately to avoid the possible additional therapeutic ef-fect of the interviews). Second, the research will aim to understand the attitudes and experiences of family physicians, department heads, and managers regarding the implementation of this type of therapy. Focus groups [22] will also be formed to explore dynamic interactions in light of cultural characteristics and concrete values that can be the basis for participants’views and preferences. In this way, qualitative information will be obtained from a collective and group vision that only emerges from indi-vidual interviews with some difficulty [23-25]. This meth-odological triangulation will increase the consistency and rigor of the study by combining multiple techniques. By placing emphasis on different aspects or perspectives of analysis, these techniques complement and balance each other [26]. The project has been approved by the Regional Ethics Committee of Aragón (Spain).
Participants
The study will be performed in the Spanish autonomous communities of Andalucía, Aragón, and Baleares. The patients will be recruited during visits to a primary care physician, and diagnosis will be established using the MINI Neuropsychiatric Interview in Spanish [27]. All participants chosen will report depressive symptoms as listed in the ICD-10 criteria, with Beck Depression Inventory (BDI) scores indicating depression of low severity (i.e., scores of 14–19) [28]. Family physicians, department heads, and managers will be chosen for the implementation of the pro-gram prepared for the randomised controlled trial. The patients and health professional participants will be selected while considering the variables that maintain homogeneity and discursive heterogeneity regarding the objectives of the study, such as age, gender, residential setting, affinity for technology, and opinion of other types of interventions or therapies. The department heads and managers, as a mi-nority group, will be chosen only based on whether their workplace is rural or urban. When recruiting patients, we will exclude those patients from the study who are younger than 18 or older than 65 years old, immigrants with lan-guage difficulties that prevent them from completing the program, affected by serious psychiatric disorders (e.g., psychosis, dementia), or demonstrate clear technophobia during the interview. Through purposive sampling, an at-tempt will be made to capture rich and varied information in agreement with the goals of the study [29], thus optimising the representation of participants’opinions.
A preliminary analysis will allow us to progress though the interviews in an iterative manner until the data are
saturated; that is, until the new information becomes re-dundant and provides no new perspectives. We hope that this will occur after approximately 10 interviews in each of the four groups (depressed patients who completed on-line psychotherapy; depressed patients who decided to discontinue online psychotherapy treatment; depressed patients who did not receive treatment online; and family physicians, department heads, and managers). After the interviews, four focus groups will be conducted, each consisting of between eight and ten subjects. An at-tempt will be made to ensure the adequate representa-tion of the stratificarepresenta-tion variables considered but with intergroup heterogeneity and intragroup homogeneity to allow the groups to be formed appropriately [24,30]. The necessary information to establish the appropriate stratifications will be collected before beginning the interviews and focus groups.
Data collection
The researchers involved in the study will receive training in qualitative social research procedures, in-depth interviews, and focus groups [22]. Topics to be addressed in both the individual interviews and focus groups will be discussed by the team of researchers and will guide the interviewers and moderators in the same direction. In-depth interviews will be carried out by a single interviewer, who will indirectly raise the objectives of the study, questioning interviewees about topics in an open and progressive way. The interviewer will also ex-plain the need for recording the session (only audio) and will take notes about non-verbal language elements. The focus groups will be moderated by an interviewer, and another person from the research team may be present as an observer. The role of the moderator will be to in-directly explain the objectives of the study, introduce the topics of interest, and direct the group dynamics to en-courage dialogue and participation. The function of the observer is limited to collecting field notes to provide additional information to the verbal data obtained, such as information related to non-verbal language, responses to the moderator’s interventions, and contextual aspects. The indirect introduction of the objectives will enable us to analyse the participants’ natural approach to the issues of interest.
routine, the possibility of developing a virtual and an-onymous relationship with the therapist, the process of online communication of thoughts and emotions, re-reading and revising the written material describing thoughts and emotions [32], information needed to ad-equately address the online therapeutic process [33], ma-terial conditions for practice, program content and personal preferences, identification with and applicability of the program, professional support and adherence, experiences of symptomatic changes and their possible re-lationship with the program [34], continual engagement with the program, and facilitators, barriers, and expected consequences that may result from this type of interven-tion [35]. Specific topics will be added to understand how to offer this therapy in the primary care context and the modification of the doctor-patient relationship that may result. When interviewing the department heads and managers, resources and risks will be addressed.
We will ensure the confidentiality and anonymous nature of the study for potential participants. All of the sessions will be audio taped with the consent of the participating subjects, and the material will be transcribed verbatim. Both the interviews and the focus groups will last approximately 60–90 minutes. The two researchers responsible for the focus groups will meet after each session to clarify and ex-change views and field notes. This information will be analysed with data from the audio recordings and notes [31].
Data analysis
The body of text (verbatim) will consist of recordings transcribed literally, supplemented by notes from
obser-vations and comments from interviewers/moderators and collaborators. The interviewers/moderators will verify the transcripts to guarantee the accuracy of the data. Final val-idation will be performed by inviting the participants to read and discuss the transcribed content [36].
The preliminary analysis will begin after the first interviews and progress through the interviews itera-tively to confirm or discount the topics found [37]. The transcriptions and notes will be reread and analysed by two independent social researchers who are experts in qualitative content analysis, using a vertical, interpretive, emergent, and non-frequency-based approach [22,38]. Through thematic analysis, supported by the initial guide for content specification as the first framework for approximation and using the constant comparative method from fundamental theory, key units of meaning will be identified that enable us to deconstruct every sentence [39]. The information contained in the gene-rated text segments will be compared and grouped through open coding until a common conceptual de-nomination for all segments of text that share the same thematic unit is reached [40]. Provisional interpre-tations will be made to highlight the characteristics and relationships of the emerging codes generated, which will form new categories as a result of their gradual fu-sion [39-41]. These broader categories, defined in an exclusive manner based on agreement among the researchers, will make the conceptual structure denser until a parsimonious solution can be reached. Cases that cannot be classified will be actively sought out during the analysis, and the emerging categories will be redefined in response to these cases [42,43].
The information gathered from focus groups will be analysed using the model of sociological analysis [44,45]. In this technique, the reading and organisation of data are not based on fragmentation of the text but on the in-terpretation of the different discursive positions among the participants and the identification of the explanatory axes of their interventions [46]. The themes and patterns will be identified and coded by two independent researchers, taking into account the context in which the interventions took place. Each step towards config-uring the potential explanatory axes will require an itera-tive reading to validate and confirm the interpretation of new findings, ensuring the credibility of the process by reviewing the data again from the beginning [47]. At first, the material from different groups will be analysed separately (intra-group analysis), but later, it will be regrouped and pooled to compare the relevant themes (inter-group analysis). The precision of the analysis will be increased by highlighting the consistent results in all groups, and special attention will be given to “sensitive moments” in the interaction as indicators of important discussions. The whole process will be triangulated
Table 1 Topic list
Areas Issues
Computer aspects -Information technology skills
-Material resources
-Routine use
Expectations -Therapeutic expectations
-Online vs. in person therapy
Experiences -Identification with the program
-Barriers and facilitators
-Changes in symptoms
Attitudes -Expressed possibilities
-Anonymous and virtual relationship
-Reflectivity of responses
Information -Information and preferences
Staff -Normalisation in primary care
-Professional support
Improvements -Interface
-Program
between the two researchers, and differences will be resolved through discussion.
To manage the data, we will use the analysis program MAXQDA 2007. The results of the thematic content ana-lysis of the interviews and the interpretation of the main explanatory axes in the focus groups will be presented alongside the empirical references in the text, selecting the most representative verbatim segments for use as examples. The researchers will develop a list of concepts identified in the interviews and focus groups and create conceptual diagrams that increase understanding and comparability. The final coding framework will be dis-cussed with the main researcher and therapy coordinator so that all stakeholders agree.
Discussion
Online computer-assisted psychotherapy seems to be an effective and cost-effective approach to treating mild to moderate depression [14,16-18]. In fact, referring pa-tients to computer-assisted psychotherapy after consult-ation in primary care could relieve some of the burden on mental health services, which are presently unable to meet the demand for mental health care [5]. Knowledge of the expectations, experiences, and attitudes of those involved in the therapeutic process is very important if this new form of treatment is to be implemented suc-cessfully. To date, research on these issues has been restricted to the perspective of the patient [32-35] with-out adequately addressing the perspectives of health officials who would be involved in recommending this type of intervention. Interestingly, these professionals show greater resistance to the use of this kind of inter-vention than the patients themselves do. The majority of patients who discontinue computer-assisted psychother-apy treatment do so for personal reasons and not because of problems with the technology or the social environ-ment [20,21]. The changes introduced to clinical practice and the doctor-patient relationship by computer-assisted psychotherapy make it important to identify the profile of patients who could benefit most from this therapeutic ap-proach. In addition, it is very important to understand the difficulties that may arise during the therapeutic process to address them and to identify facilitators for completing the treatment.
Qualitative research methods provide a thorough understanding of the perceptions, beliefs, and values of the people being studied, and they are very useful in the health field [48,49]. These methods provide the oppor-tunity to explore the points of view of both patients and medical personnel involved in the therapeutic process, thus helping researchers to understand them [29]. This study does not quantify the hypothetical positive or negative aspects of online therapeutic intervention or the correlations between opinions and other types of
variables [25,50]. Through this research, an attempt is made to understand the values and experiences of the participants in the context of the study, which are valid to the extent that they contribute to the knowledge and understanding of the therapeutic reality of this type of intervention.
Competing interests
The authors declare that they have no competing interests.
Authors’contribution
JM-M, JMC, ASB, MR, MG, RB, CB, RA and JG-C conceptualised the study. JM-M wrote the manuscript and all authors participated in critically revising for important intellectual content and have given final approval of the version to be published.
Authors’information
Jesús Montero-Marín, Javier García-Campayo, Miquel Roca, Antoni Serrano-Blanco, Margalida Gili, Fermín Mayoral, Juan V. Luciano, Yolanda López del Hoyo and Bárbara Oliván belong to the REDIAPP (Research Network on Preventative Activities and Health Promotion, RD06/0018/0017).
Acknowledgements
This project is funded by the Instituto de Salud Carlos III [Carlos III Health Institute] (PI10/01083) and the Ministerio de Ciencia e Innovación [Ministry of Science and Innovation] (PSI2010-17563). The publication of this document was made possible within the framework of collaboration designed by the Research Network on Preventative Activities and Health Promotion (REDIAPP).
Author details
1Department of Psychiatry, University of Zaragoza, Zaragoza, Spain.2Faculty
of Health and Sports, University of Zaragoza, Huesca, Spain.3Research Unit, Sociedad Española de Reumatología, Madrid, Spain.4Institut Universitari d’Investigació en Ciències de la Salut (IUNICS), University of Balearic Islands, Palma de Mallorca, Spain.5Parc Sanitari Sant Joan de Déu, and Fundación Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.6Psychiatric Service, University Hospital Carlos Haya, Malaga, Spain.7Departamento de Psicología y Sociología, Universidad de Zaragoza, Zaragoza, Spain.8Servei de Psiquiatria, Hospital Universitari Vall d’Hebron, Barcelona, Spain.9Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK.10University of Valencia, Valencia, Spain.11Jaume I University, Castellón, Spain.12CIBER Pathophysiology of Obesity and Nutrition (CB06/03), Carlos III Institute of Health, Madrid, Spain.13Psychiatry Service, Miguel Servet Hospital, Avda Gomez Laguna 52, Zaragoza 4D 50.009, Spain.
Received: 20 April 2012 Accepted: 13 February 2013 Published: 20 February 2013
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doi:10.1186/1471-244X-13-64
Cite this article as:Montero-Marínet al.:Expectations, experiences and attitudes of patients and primary care health professionals regarding online psychotherapeutic interventions for depression: protocol for a qualitative study.BMC Psychiatry201313:64.
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